NCC215815_FRO Submitted_20211019

CITY OF GREENSBORO
FINANCIAL RESPONSIBILITY/C)WNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity covered by the Sedimentation Pollution Control Act before this form
has been completed and filed with the Sediment and Erosion Control Section of the City of Greensboro. (Please type
or print and, if questions are not applicable, place NIA in the blank).
Part A:
1. Project Name: MackayPointe
2. Location of land -disturbing activity: 5281 MackayRoad
3. Approximate date land disturbing activity will be commenced: July 2021
4. Development type: Commercial industrial Institutional ✓ MF residential SF residential
5. Approximate acreage of land to be disturbed: 14.12
6. Has an erosion and sediment control plan been filed? Yes ✓ No
7. Landowner(s) of Record (attach pages to list additional owners):
Mackay Road, LLC 336-708-2619 [e-mail]
Name Telephone Email
3705-A W. Market St, 3705-A W. Market St.
Current Mailing Address Current Physical Street Address
Greensboro NC 27403 Greensboro NC 27403
City State Zip City State Zip
8. Deed County: Guilford Book: 8382 Page: 154 232
9. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name: Arnold Sykes Telephone: [phone]
E-mail: was kes mail.com Other:
Part B:
1. Company(ies) or firm(s) who are financially responsible for the land -disturbing activity (Provide a comprehensive
list of all responsible parties on an attached sheet.) If the company or firm is a sole proprietorship the name of the owner
or manager may be listed as the financially responsible party.
MackayRoad LLC 336-708.2619 was kes mail.com
Name Telephone Email
3705-A W. Market St. 3705-A W. Market St.
Current Mailing Address Current Physical Street Address
Greensboro NC 27403 Greensboro NC
City State Zip City State zip
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2, (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address of the
designated North Carolina Agent:
Name
Current Mailing Address
City State
Zip
Telephone
Email
Current Physical Street Address
City State
Zip
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an assumed
name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible Party is a Corporation,
give name and street address of the Registered Agent:
Name
Current Mailing Address
City State Zip
Telephone
Email
Current Physical Street Address
City State
Zip
The above information is true and correct to the best of my knowledge and belief and was provided by me
under oath (This form must be signed by the Financially Responsible Person if an individual or his attorney -
in -fact, or if not an individual, by an officer, director, partner, or registered agent with the authority to execute
instruments for the Financially Responsible Person). I agree to provide corrected information should there
be any change in the information provided herein.
Cranford A. Jones
Type or print name
Signature
Manager
Title or Authority
Date
to -/S-2 /
I , a Notary Public of the County of
State of hereby certify that �� 1rD,A�{ll
Personally accepted before met day and u
executed by owner(s). er oath acknowledged that the above form was
••••.• d r�d►fPotarial seal; this J�E day of 20
9=�
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